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Fouladi A, Asadi A, Sherer EA, Madadi M. Cost-effectiveness Analysis of Colorectal Cancer Screening Strategies Using Active Learning and Monte Carlo Simulation. Med Decis Making 2024:272989X241258224. [PMID: 38907706 DOI: 10.1177/0272989x241258224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2024]
Abstract
INTRODUCTION Detection of colorectal cancer (CRC) in the early stages through available screening tests increases the patient's survival chances. Multimodal screening policies can benefit patients by providing more diverse screening options and balancing the risks and benefits of screening tests. We investigate the cost-effectiveness of a wide variety of multimodal CRC screening policies. METHODS We developed a Monte Carlo simulation framework to model CRC dynamics. We proposed an innovative calibration process using machine learning models to estimate age- and size-specific adenomatous polyps' progression and regression rates. The proposed approach significantly expedites the model parameter space search. RESULTS Two multimodal proposed policies (i.e., 1] colonoscopy at 50 y and fecal occult blood test annually between 60 and 75 y and 2] colonoscopy at 50 and 60 y and fecal immunochemical test annually between 70 and 75 y) are identified as efficient frontier policies. Both policies are cost-effective at a willingness to pay of $50,000. Sensitivity analyses were performed to assess the sensitivity of results to a change in screening test costs as well as adherence behavior. The sensitivity analysis results suggest that the proposed policies are mostly robust to the considered changes in screening test costs, as there is a significant overlap between the efficient frontier policies of the baseline and the sensitivity analysis cases. However, the efficient frontier policies were more sensitive to changes in adherence behavior. CONCLUSION Generally, combining stool-based tests with visual tests will benefit patients with higher life expectancy and a lower expected cost compared with unimodal screening policies. Colonoscopy at younger ages (when the colonoscopy complication risk is lower) and stool-based tests at older ages are shown to be more effective. HIGHLIGHTS We propose a detailed Markov model to capture the colorectal cancer (CRC) dynamics. The proposed Markov model presents the detailed dynamics of adenomas progression to CRC.We use more than 44,000 colonoscopy reports and available data in the literature to calibrate the proposed Markov model using an innovative approach that leverages machine learning models to expedite the calibration process.We investigate the cost-effectiveness of a wide variety of multimodal CRC screening policies and compare their performances with the current in-practice policies.
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Affiliation(s)
| | - Amin Asadi
- Data Science, AI, OR, and Logistics, University of Twente, Twente, Netherlands
| | - Eric A Sherer
- Chemical Engineering, Louisiana Tech University, Ruston, LA, USA
| | - Mahboubeh Madadi
- Marketing and Business Analytics, San Jose State University, San Jose, CA, USA
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2
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Kildusiene I, Dulskas A, Smailyte G. Value of combined serum CEA, CA72-4, and CA19-9 marker detection in diagnosis of colorectal cancer. Tech Coloproctol 2024; 28:33. [PMID: 38358422 DOI: 10.1007/s10151-023-02873-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/18/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND The aim of this study was to examine whether the combination of serum tumor markers (carcinoembryonic antigen [CEA], carbohydrate antigen [CA]72-4, CA19-9) improves sensitivity and accuracy in the diagnosis of colorectal cancer and precancerous lesion tubular adenoma. METHODS An automatic electrochemiluminescence immunoassay with matched kits (ECLIA) was performed on a Roche Cobas e411 analyzer to determine the levels of serum CEA, CA72-4, and CA19-9 in 35 patients with early colorectal cancer, 87 patients with tubular adenoma, and 58 healthy people undergoing colonoscopy after positive fecal immunochemical test (FIT) in a colorectal cancer screening program 2021 January to April. The values of these three tumor markers in the diagnosis of colorectal cancer and tubular adenoma were analyzed. RESULTS 180 patients (92 female and 88 male) were included into the study. We compared serum CEA, CA72-4 and CA19-9 markers among 3 groups: healthy people (mean age 64,0 ±8,6), patients with tubular adenoma (mean age 62,7 ± 6,4) and colorectal cancer (mean age 59,2 ±6,2). The levels of serum CEA, CA72-4, and CA19-9 were higher in the colorectal cancer group than in the tubular adenoma group and healthy subjects, and these differences were significant (p < 0.05). The combination of CEA, CA72-4, and CA19-9 had a higher diagnostic value for colorectal cancer compared to single markers, and the positive detection rate was 54.3%. The diagnostic power when using all three markers was the best, and applied for colorectal cancer and tubular adenoma. CONCLUSIONS The combination of CA72-4, CEA, and CA19-9 markers increases the sensitivity and accuracy in the diagnosis of colorectal cancer and can thus be considered an important tool for early colorectal diagnosis.
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Affiliation(s)
- I Kildusiene
- Life Sciences Centre, Vilnius University, 03101, Vilnius, Lithuania.
- Laboratory of Cancer Epidemiology, National Cancer Institute, Vilnius, Lithuania.
| | - A Dulskas
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Department of Abdominal and General Surgery and Oncology, National Cancer Institute, Vilnius, Lithuania
| | - G Smailyte
- Laboratory of Cancer Epidemiology, National Cancer Institute, Vilnius, Lithuania
- Institute of Health Sciences, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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Dai JY, Zhang J, Braun JV, Simon N, Hubbell E, Zhang N. Clinical performance and utility: A microsimulation model to inform the design of screening trials for a multi-cancer early detection test. J Med Screen 2024:9691413241228041. [PMID: 38304990 DOI: 10.1177/09691413241228041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
OBJECTIVES Designing cancer screening trials for multi-cancer early detection (MCED) tests presents a significant methodology challenge, as natural histories of cell-free DNA-shedding cancers are not yet known. A microsimulation model was developed to project the performance and utility of an MCED test in cancer screening trials. METHODS Individual natural history of preclinical progression through cancer stages for 23 cancer classes was simulated by a stage-transition model under a broad range of cancer latency parameters. Cancer incidences and stage distributions at clinical presentation in simulated trials were set to match the data from Surveillance, Epidemiology, and End Results program. One or multiple rounds of annual screening using a targeted methylation-based MCED test (GalleriⓇ) was conducted to detect preclinical cancers. Mortality benefit of early detection was simulated by a stage-shift model. RESULTS In simulated trials, accounting for healthy volunteer effect and varying test sensitivity, positive predictive value in the prevalence screening round reached 48% to 61% in 6 natural history scenarios. After 3 rounds of annual screening, the cumulative proportions of stage I/II cancers increased by approximately 9% to 14%, the incidence of stage IV cancers was reduced by 37% to 46%, the reduction of stages III and IV cancer incidences was 9% to 24%, and the reduction of mortality reached 13% to 16%. Greater reductions of late-stage cancers and cancer mortality were achieved by five rounds of MCED screening. CONCLUSIONS Simulation results guide trial design and suggest that adding this MCED test to routine screening in the United States may shift cancer detection to earlier stages, and potentially save lives.
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Affiliation(s)
| | | | | | - Noah Simon
- Department of Biostatistics, University of Washington, Seattle, WA, USA
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Xia C, Chen W. The NCC mathematical modeling framework for decision-making of six major cancers. JOURNAL OF THE NATIONAL CANCER CENTER 2022. [DOI: 10.1016/j.jncc.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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5
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Cadham CJ, Knoll M, Sánchez-Romero LM, Cummings KM, Douglas CE, Liber A, Mendez D, Meza R, Mistry R, Sertkaya A, Travis N, Levy DT. The Use of Expert Elicitation among Computational Modeling Studies in Health Research: A Systematic Review. Med Decis Making 2021; 42:684-703. [PMID: 34694168 DOI: 10.1177/0272989x211053794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Expert elicitation (EE) has been used across disciplines to estimate input parameters for computational modeling research when information is sparse or conflictual. OBJECTIVES We conducted a systematic review to compare EE methods used to generate model input parameters in health research. DATA SOURCES PubMed and Web of Science. STUDY ELIGIBILITY Modeling studies that reported the use of EE as the source for model input probabilities were included if they were published in English before June 2021 and reported health outcomes. DATA ABSTRACTION AND SYNTHESIS Studies were classified as "formal" EE methods if they explicitly reported details of their elicitation process. Those that stated use of expert opinion but provided limited information were classified as "indeterminate" methods. In both groups, we abstracted citation details, study design, modeling methodology, a description of elicited parameters, and elicitation methods. Comparisons were made between elicitation methods. STUDY APPRAISAL Studies that conducted a formal EE were appraised on the reporting quality of the EE. Quality appraisal was not conducted for studies of indeterminate methods. RESULTS The search identified 1520 articles, of which 152 were included. Of the included studies, 40 were classified as formal EE and 112 as indeterminate methods. Most studies were cost-effectiveness analyses (77.6%). Forty-seven indeterminate method studies provided no information on methods for generating estimates. Among formal EEs, the average reporting quality score was 9 out of 16. LIMITATIONS Elicitations on nonhealth topics and those reported in the gray literature were not included. CONCLUSIONS We found poor reporting of EE methods used in modeling studies, making it difficult to discern meaningful differences in approaches. Improved quality standards for EEs would improve the validity and replicability of computational models. HIGHLIGHTS We find extensive use of expert elicitation for the development of model input parameters, but most studies do not provide adequate details of their elicitation methods.Lack of reporting hinders greater discussion of the merits and challenges of using expert elicitation for model input parameter development.There is a need to establish expert elicitation best practices and reporting guidelines.
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Affiliation(s)
- Christopher J Cadham
- Department of Health Management and Policy, University of Michigan, School of Public Health, Ann Arbor, MI, USA
| | - Marie Knoll
- Georgetown University, Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | | | - K Michael Cummings
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Clifford E Douglas
- Department of Health Management and Policy, University of Michigan, School of Public Health, Ann Arbor, MI, USA.,University of Michigan, Tobacco Research Network, Ann Arbor, MI, USA
| | - Alex Liber
- Georgetown University, Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - David Mendez
- Department of Health Management and Policy, University of Michigan, School of Public Health, Ann Arbor, MI, USA
| | - Rafael Meza
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Ritesh Mistry
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | | - Nargiz Travis
- Department of Health Management and Policy, University of Michigan, School of Public Health, Ann Arbor, MI, USA.,Georgetown University, Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - David T Levy
- Georgetown University, Lombardi Comprehensive Cancer Center, Washington, DC, USA
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Ykema BLM, Bisseling TM, Spaander MCW, Moons LMG, van der Biessen-van Beek D, Saveur L, Kerst M, Mulder SF, de Wit R, Zweers D, Meijer GA, Beijnen JH, Lansdorp-Vogelaar I, van Leeuwen FE, Snaebjornsson P, van Leerdam ME. Diagnostic yield of colonoscopy surveillance in testicular cancer survivors treated with platinum-based chemotherapy: study protocol of a prospective cross-sectional cohort study. BMC Gastroenterol 2021; 21:67. [PMID: 33579196 PMCID: PMC7881638 DOI: 10.1186/s12876-021-01639-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/02/2021] [Indexed: 01/01/2023] Open
Abstract
Background Testicular cancer (TC) survivors have an increased risk of various second primary malignancies. A recent cohort study detected an increased risk of colorectal cancer (CRC) in TC survivors treated with platinum-based chemotherapy with a hazard ratio of 3.9. CRC risk increased with higher cisplatin-dose. We know that colonoscopy surveillance in high-risk populations results in reduced incidence and mortality of CRC. TC survivors treated with platinum-based chemotherapy can potentially benefit from colonoscopy surveillance; however, to which extent is unknown. Furthermore, the pathogenesis of these secondary CRCs is unknown, and better insights into the carcinogenesis may affect surveillance decisions. Methods This prospective multicenter study will be performed in four Dutch hospitals. TC survivors are eligible if treated with ≥ 3 cycles of cisplatin before age 50. Colonoscopy will be performed ≥ 8 years after initial treatment (minimum and maximum ages at colonoscopy, 35 and 75 years, respectively). The primary aim of the study is the diagnostic yield of advanced neoplasia detected during colonoscopy. As secondary aim, we will evaluate the molecular profile of advanced colorectal neoplasia and will assess current platinum levels in blood and urine and correlate blood-platinum levels with prevalence of colorectal lesions. Furthermore, we will investigate effectiveness of fecal immunochemical testing (FIT) and burden of colonoscopy by two questionnaires. Demographic data, previous history, results of colonoscopy, hemoglobin level of FIT and results of molecular and platinum levels will be obtained. Yield of colonoscopy will be determined by detection rate of adenoma and serrated lesions, advanced adenoma detection rate and CRC detection rate. The MISCAN model will be used for cost-effectiveness analyses of CRC surveillance. With 234 participants undergoing colonoscopy, we can detect an absolute difference of 6% of advanced neoplasia with 80% power. Discussion TC survivors treated with cisplatin-based chemotherapy can benefit from CRC surveillance. Evaluation of the diagnostic performance and patient acceptance of CRC surveillance is of importance to develop surveillance recommendations. Insight into the carcinogenesis of cisplatin-related advanced colorectal lesions will contribute to CRC prevention in the increasing number of TC survivors. The results may also be important for the many other cancer survivors treated with platinum-based chemotherapy. Trial registration Clinical Trials: NCT04180033, November 27, 2019, https://clinicaltrials.gov/ct2/show/NCT04180033.
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Affiliation(s)
- Berbel L M Ykema
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
| | - Tanya M Bisseling
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Lisette Saveur
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Martijn Kerst
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Sasja F Mulder
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ronald de Wit
- Department of Medical Oncology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Danielle Zweers
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gerrit A Meijer
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy and Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Flora E van Leeuwen
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Petur Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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7
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Barré S, Leleu H, Vimont A, Kaufmanis A, Gendre I, Taleb S, De Bels F. [Estimated impact of the current colorectal screening program in France]. Rev Epidemiol Sante Publique 2020; 68:171-177. [PMID: 32417153 DOI: 10.1016/j.respe.2020.04.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/13/2020] [Accepted: 04/29/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Colorectal cancer is the third most common cancer and the second most deadly in France. A Cochrane meta-analysis has confirmed the benefits of colorectal cancer screening. A nationwide colorectal screening program was set up in France in 2009 for medium-risk, asymptomatic people aged 50 to 74 years. It has been based, since 2015, on the Fecal Immunochemical Test. The participation rate for 2016-2017 was 34%, which is lower than the European objectives. The objective of this study was to evaluate the impact of the program at the current participation rate and at rates of 45% and 65%. METHODS The epidemiological impact of the program was estimated from the results of an individual simulation model adapted from the Microsimulation Screening Analysis Colon model, calibrated and transposed to the French context. An initial analysis was conducted to estimate the individual impact of screening and a second for the entire eligible population, at various participation rates. RESULTS The test is associated with a lifetime reduction in the risk of colorectal cancer of 24% for men and 21% for women, and a reduction in the risk of death from colorectal cancer of 51% and 43% respectively. At the current level of participation, the program reduces incidence by 5% and mortality by 14% compared to no organized screening. The impact would be reduced by an additional 3% and 8% for participation rates of 45% and 65% respectively. Similarly, mortality would decrease by an additional 8% and 22%. CONCLUSION These results confirm that in a population at medium risk for colorectal cancer, the organised programme is an effective strategy for reducing its incidence. They also confirm that the achievement of European objectives remains a key issue for improving the effectiveness of organized screening. An evolution of immunological test delivery modalities could help to achieve these participation objectives.
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Affiliation(s)
- S Barré
- Institut national du cancer, Boulogne-Billancourt, France
| | - H Leleu
- Public Health Expertise, Paris, France
| | - A Vimont
- Public Health Expertise, Paris, France
| | - A Kaufmanis
- Centre de coordination des dépistages des cancers - région Île-de-France, Paris, France
| | - I Gendre
- Centre de coordination des dépistages des cancers - région Grand-Est, Vandœuvre-lès-Nancy, France
| | - S Taleb
- Institut national du cancer, Boulogne-Billancourt, France.
| | - F De Bels
- Institut national du cancer, Boulogne-Billancourt, France
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Gao Y, Wang J, Zhou Y, Sheng S, Qian SY, Huo X. Evaluation of Serum CEA, CA19-9, CA72-4, CA125 and Ferritin as Diagnostic Markers and Factors of Clinical Parameters for Colorectal Cancer. Sci Rep 2018; 8:2732. [PMID: 29426902 PMCID: PMC5807317 DOI: 10.1038/s41598-018-21048-y] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/26/2018] [Indexed: 12/15/2022] Open
Abstract
Blood-based protein biomarkers have recently shown as simpler diagnostic modalities for colorectal cancer, while their association with clinical pathological characteristics is largely unknown. In this study, we not only examined the sensitivity and reliability of single/multiple serum markers for diagnosis, but also assessed their connection with pathological parameters from a total of 279 colorectal cancer patients. Our study shown that glycoprotein carcinoembryonic antigen (CEA) owns the highest sensitivity among single marker in the order of CEA > cancer antigen 72-4 (CA72-4) > cancer antigen 19-9 9 (CA19-9) > ferritin > cancer antigen 125 (CA125), while the most sensitive combined-markers for two to five were: CEA + CA72-4; CEA + CA72-4 + CA125; CEA + CA19-9 + CA72-4 + CA125; and CEA + CA19-9 + CA72-4 + CA125 + ferritin, respectively. We also demonstrated that patients who had positive preoperative serum CEA, CA19-9, or CA72-4 were more likely with lymph node invasion, positive CA125 were prone to have vascular invasion, and positive CEA or CA125 were correlated with perineural invasion. In addition, positive CA19-9, CA72-4, or CA125 was associated with poorly differentiated tumor, while CEA, CA19-9, CA72-4, CA125 levels were positively correlated with pathological tumor-node-metastasis stages. We here conclude that combined serum markers can be used to not only diagnose colorectal cancer, but also appraise the tumor status for guiding treatment, evaluation of curative effect, and prognosis of patients.
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Affiliation(s)
- Yanfeng Gao
- Department of Anesthesiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jinping Wang
- Department of Gynecology, the Northwest Women and Children Hospital, Xi'an, China
| | - Yue Zhou
- Department of Statistics, North Dakota State University, North Dakota, 58102, USA
| | - Sen Sheng
- Department of Neurosurgery, Neuroscience Institute, Baylor Scott and White Health, Temple, Texas, 76502, USA
| | - Steven Y Qian
- Department of Pharmaceutical Sciences, North Dakota State University, North Dakota, 58105, USA.
| | - Xiongwei Huo
- Department of General Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
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Von Renteln D, Bouin M, Barkun AN. Current standards and new developments of colorectal polyp management and resection techniques. Expert Rev Gastroenterol Hepatol 2017; 11:835-842. [PMID: 28319429 DOI: 10.1080/17474124.2017.1309279] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Colonoscopy and endoscopic removal of precancerous polyps play an important role in colorectal cancer (CRC) prevention. Improved endoscopes and quality standards have led to an increasing polyp and adenoma detection rate. Optimal polyp resection techniques and management strategies are key for an effective colonoscopy practice. Areas covered: Strategies for how to improve diminutive polyp (polyps up to 5 mm in size) management are discussed because of their high prevalence. Systematic removal of diminutive polyps leads to increasing costs of colonoscopy practice, while the effect on colorectal cancer prevention might be negligible. Furthermore, polypectomy recommendations for mid-size and large polyps are provided. For all larger polyps larger, complete and safe resection is mandatory to avoid post colonoscopy cancers. The focus for managing such larger polyps is to use new techniques (i.e. cold snares) and to attempt complete removal and to reduce post-polypectomy complications. Expert commentary: The resect-and-discard strategy is a promising management strategy for diminutive polyps. However, modification of this approach might be required in order to make widespread adoption feasible. Cold snare polypectomy is a promising new approach for small polyp resection. For resection of large polyps adequate treatment recommendations with regard to endoscopic mucosal resection and complication prevention are provided.
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Affiliation(s)
- Daniel Von Renteln
- a Department of Medicine, Division of Gastroenterology , Montreal University Hospital (CHUM) , Montreal , Canada
| | - Mickael Bouin
- a Department of Medicine, Division of Gastroenterology , Montreal University Hospital (CHUM) , Montreal , Canada
| | - Alan N Barkun
- b Division of Gastroenterology , McGill University Health Center, McGill University , Montreal , Quebec , Canada
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Estimating the Effect of Targeted Screening Strategies: An Application to Colonoscopy and Colorectal Cancer. Epidemiology 2017; 28:470-478. [PMID: 28368944 PMCID: PMC5453827 DOI: 10.1097/ede.0000000000000668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Supplemental Digital Content is available in the text. Screening behavior depends on previous screening history and family members’ behaviors, which can act as both confounders and intermediate variables on a causal pathway from screening to disease risk. Conventional analyses that adjust for these variables can lead to incorrect inferences about the causal effect of screening if high-risk individuals are more likely to be screened. Analyzing the data in a manner that treats screening as randomized conditional on covariates allows causal parameters to be estimated; inverse probability weighting based on propensity of exposure scores is one such method considered here. I simulated family data under plausible models for the underlying disease process and for screening behavior to assess the performance of alternative methods of analysis and whether a targeted screening approach based on individuals’ risk factors would lead to a greater reduction in cancer incidence in the population than a uniform screening policy. Simulation results indicate that there can be a substantial underestimation of the effect of screening on subsequent cancer risk when using conventional analysis approaches, which is avoided by using inverse probability weighting. A large case–control study of colonoscopy and colorectal cancer from Germany shows a strong protective effect of screening, but inverse probability weighting makes this effect even stronger. Targeted screening approaches based on either fixed risk factors or family history yield somewhat greater reductions in cancer incidence with fewer screens needed to prevent one cancer than population-wide approaches, but the differences may not be large enough to justify the additional effort required. See video abstract at, http://links.lww.com/EDE/B207.
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Goede SL, Rabeneck L, van Ballegooijen M, Zauber AG, Paszat LF, Hoch JS, Yong JHE, Kroep S, Tinmouth J, Lansdorp-Vogelaar I. Harms, benefits and costs of fecal immunochemical testing versus guaiac fecal occult blood testing for colorectal cancer screening. PLoS One 2017; 12:e0172864. [PMID: 28296927 PMCID: PMC5351837 DOI: 10.1371/journal.pone.0172864] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 02/12/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The ColonCancerCheck screening program for colorectal cancer (CRC) in Ontario, Canada, is considering switching from biennial guaiac fecal occult blood test (gFOBT) screening between age 50-74 years to the more sensitive, but also less specific fecal immunochemical test (FIT). The aim of this study is to estimate whether the additional benefits of FIT screening compared to gFOBT outweigh the additional costs and harms. METHODS We used microsimulation modeling to estimate quality adjusted life years (QALYs) gained and costs of gFOBT and FIT, compared to no screening, in a cohort of screening participants. We compared strategies with various age ranges, screening intervals, and cut-off levels for FIT. Cost-efficient strategies were determined for various levels of available colonoscopy capacity. RESULTS Compared to no screening, biennial gFOBT screening between age 50-74 years provided 20 QALYs at a cost of CAN$200,900 per 1,000 participants, and required 17 colonoscopies per 1,000 participants per year. FIT screening was more effective and less costly. For the same level of colonoscopy requirement, biennial FIT (with a high cut-off level of 200 ng Hb/ml) between age 50-74 years provided 11 extra QALYs gained while saving CAN$333,300 per 1000 participants, compared to gFOBT. Without restrictions in colonoscopy capacity, FIT (with a low cut-off level of 50 ng Hb/ml) every year between age 45-80 years was the most cost-effective strategy providing 27 extra QALYs gained per 1000 participants, while saving CAN$448,300. INTERPRETATION Compared to gFOBT screening, switching to FIT at a high cut-off level could increase the health benefits of a CRC screening program without considerably increasing colonoscopy demand.
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Affiliation(s)
- S. Lucas Goede
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Linda Rabeneck
- Prevention and Cancer Control, Cancer Care Ontario, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | | | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | | | - Jeffrey S. Hoch
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Centre for Excellence in Economic Analysis Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Jean H. E. Yong
- Centre for Excellence in Economic Analysis Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Sonja Kroep
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jill Tinmouth
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Department of Medicine, Division of Gastroenterology, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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Rigter LS, Spaander MCW, Moons LM, Bisseling TM, Aleman BMP, de Boer JP, Lugtenburg PJ, Janus CPM, Petersen EJ, Roesink JM, Raemaekers JMM, van der Maazen RWM, Cats A, Bleiker EMA, Snaebjornsson P, Carvalho B, Lansdorp-Vogelaar I, Jóźwiak K, Te Riele H, Meijer GA, van Leeuwen FE, van Leerdam ME. Colorectal cancer surveillance in Hodgkin lymphoma survivors at increased risk of therapy-related colorectal cancer: study design. BMC Cancer 2017; 17:112. [PMID: 28173773 PMCID: PMC5297162 DOI: 10.1186/s12885-017-3089-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 01/20/2017] [Indexed: 02/08/2023] Open
Abstract
Background Second primary malignancies are a major cause of excess morbidity and mortality in cancer survivors. Hodgkin lymphoma survivors who were treated with infradiaphragmatic radiotherapy and/or high-dose procarbazine have an increased risk to develop colorectal cancer. Colonoscopy surveillance plays an important role in colorectal cancer prevention by removal of the precursor lesions (adenomas) and early detection of cancer, resulting in improved survival rates. Therefore, Hodgkin lymphoma survivors treated with infradiaphragmatic radiotherapy and/or high-dose procarbazine could benefit from colonoscopy, or other surveillance modalities, which are expected to reduce colorectal cancer incidence and mortality. Current knowledge on clinicopathological and molecular characteristics of therapy-related colorectal cancer is limited. The pathogenesis of such colorectal cancers might be different from the pathogenesis in the general population and therefore these patients might require a different clinical approach. We designed a study with the primary aim to assess the diagnostic yield of a first surveillance colonoscopy among Hodgkin lymphoma survivors at increased risk of colorectal cancer and to compare these results with different screening modalities in the general population. Secondary aims include assessment of the test characteristics of stool tests and evaluation of burden, acceptance and satisfaction of CRC surveillance through two questionnaires. Methods/Design This prospective multicenter cohort study will include Hodgkin lymphoma survivors who survived ≥8 years after treatment with infradiaphragmatic radiotherapy and/or procarbazine (planned inclusion of 259 participants). Study procedures will consist of a surveillance colonoscopy with removal of precursor lesions (adenomas) and 6–8 normal colonic tissue biopsies, a fecal immunochemical test and a stool DNA test. All neoplastic lesions encountered will be classified using relevant histomorphological, immunohistochemical and molecular analyses in order to obtain more insight into colorectal carcinogenesis in Hodgkin lymphoma survivors. The Miscan-model will be used for cost-effectiveness analyses. Discussion Evaluation of the diagnostic performance, patient acceptance and burden of colorectal cancer surveillance is necessary for future implementation of an individualized colorectal cancer surveillance program for Hodgkin lymphoma survivors. In addition, more insight into treatment-induced colorectal carcinogenesis will provide the first step towards prevention and personalized treatment. This information may be extrapolated to other groups of cancer survivors. Trial registration Registered at the Dutch Trial Registry (NTR): NTR4961.
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Affiliation(s)
- Lisanne S Rigter
- Department of Gastroenterology, Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066 CX, The Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Leon M Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tanya M Bisseling
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Berthe M P Aleman
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jan Paul de Boer
- Department of Hematology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Cecile P M Janus
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Eefke J Petersen
- Department of Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Judith M Roesink
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - John M M Raemaekers
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Annemieke Cats
- Department of Gastroenterology, Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066 CX, The Netherlands
| | - Eveline M A Bleiker
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Petur Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Beatriz Carvalho
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Katarzyna Jóźwiak
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hein Te Riele
- Division of Biological Stress Response, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Gerrit A Meijer
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Flora E van Leeuwen
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology, Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066 CX, The Netherlands.
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Kingsley J, Karanth S, Revere FL, Agrawal D. Cost Effectiveness of Screening Colonoscopy Depends on Adequate Bowel Preparation Rates - A Modeling Study. PLoS One 2016; 11:e0167452. [PMID: 27936028 PMCID: PMC5147887 DOI: 10.1371/journal.pone.0167452] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 11/14/2016] [Indexed: 02/07/2023] Open
Abstract
Background Inadequate bowel preparation during screening colonoscopy necessitates repeating colonoscopy. Studies suggest inadequate bowel preparation rates of 20–60%. This increases the cost of colonoscopy for our society. Aim The aim of this study is to determine the impact of inadequate bowel preparation rate on the cost effectiveness of colonoscopy compared to other screening strategies for colorectal cancer (CRC). Methods A microsimulation model of CRC screening strategies for the general population at average risk for CRC. The strategies include fecal immunochemistry test (FIT) every year, colonoscopy every ten years, sigmoidoscopy every five years, or stool DNA test every 3 years. The screening could be performed at private practice offices, outpatient hospitals, and ambulatory surgical centers. Results At the current assumed inadequate bowel preparation rate of 25%, the cost of colonoscopy as a screening strategy is above society’s willingness to pay (<$50,000/QALY). Threshold analysis demonstrated that an inadequate bowel preparation rate of 13% or less is necessary before colonoscopy is considered more cost effective than FIT. At inadequate bowel preparation rates of 25%, colonoscopy is still more cost effective compared to sigmoidoscopy and stool DNA test. Sensitivity analysis of all inputs adjusted by ±10% showed incremental cost effectiveness ratio values were influenced most by the specificity, adherence, and sensitivity of FIT and colonoscopy. Conclusions Screening colonoscopy is not a cost effective strategy when compared with fecal immunochemical test, as long as the inadequate bowel preparation rate is greater than 13%.
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Affiliation(s)
- James Kingsley
- Department of Internal Medicine, Texas Health Presbyterian Hospital, Dallas, Texas, United States of America
| | - Siddharth Karanth
- School of Public Health, University of Texas Health Science Center, Houston, Texas, United States of America
| | - Frances Lee Revere
- School of Public Health, University of Texas Health Science Center, Houston, Texas, United States of America
| | - Deepak Agrawal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- * E-mail:
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Greuter MJE, Xu XM, Lew JB, Dekker E, Kuipers EJ, Canfell K, Meijer GA, Coupé VMH. Modeling the Adenoma and Serrated pathway to Colorectal CAncer (ASCCA). RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2014; 34:889-910. [PMID: 24172539 DOI: 10.1111/risa.12137] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Several colorectal cancer (CRC) screening models have been developed describing the progression of adenomas to CRC. Currently, there is increasing evidence that serrated lesions can also develop into CRC. It is not clear whether screening tests have the same test characteristics for serrated lesions as for adenomas, but lower sensitivities have been suggested. Models that ignore this type of colorectal lesions may provide overly optimistic predictions of the screen-induced reduction in CRC incidence. To address this issue, we have developed the Adenoma and Serrated pathway to Colorectal CAncer (ASCCA) model that includes the adenoma-carcinoma pathway and the serrated pathway to CRC as well as characteristics of colorectal lesions. The model structure and the calibration procedure are described in detail. Calibration resulted in 19 parameter sets for the adenoma-carcinoma pathway and 13 for the serrated pathway that match the age- and sex-specific adenoma and serrated lesion prevalence in the COlonoscopy versus COlonography Screening (COCOS) trial, Dutch CRC incidence and mortality rates, and a number of other intermediate outcomes concerning characteristics of colorectal lesions. As an example, we simulated outcomes for a biennial fecal immunochemical test screening program and a hypothetical one-time colonoscopy screening program. Inclusion of the serrated pathway influenced the predicted effectiveness of screening when serrated lesions are associated with lower screening test sensitivity or when they are not removed. To our knowledge, this is the first model that explicitly includes the serrated pathway and characteristics of colorectal lesions. It is suitable for the evaluation of the (cost)effectiveness of potential screening strategies for CRC.
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Jeong KE, Cairns JA. Review of economic evidence in the prevention and early detection of colorectal cancer. HEALTH ECONOMICS REVIEW 2013; 3:20. [PMID: 24229442 PMCID: PMC3847082 DOI: 10.1186/2191-1991-3-20] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 08/23/2013] [Indexed: 05/20/2023]
Abstract
This paper aims to systematically review the cost-effectiveness evidence, and to provide a critical appraisal of the methods used in the model-based economic evaluation of CRC screening and subsequent surveillance. A search strategy was developed to capture relevant evidence published 1999-November 2012. Databases searched were MEDLINE, EMBASE, National Health Service Economic Evaluation (NHS EED), EconLit, and HTA. Full economic evaluations that considered costs and health outcomes of relevant intervention were included. Sixty-eight studies which used either cohort simulation or individual-level simulation were included. Follow-up strategies were mostly embedded in the screening model. Approximately 195 comparisons were made across different modalities; however, strategies modelled were often simplified due to insufficient evidence and comparators chosen insufficiently reflected current practice/recommendations. Studies used up-to-date evidence on the diagnostic test performance combined with outdated information on CRC treatments. Quality of life relating to follow-up surveillance is rare. Quality of life relating to CRC disease states was largely taken from a single study. Some studies omitted to say how identified adenomas or CRC were managed. Besides deterministic sensitivity analysis, probabilistic sensitivity analysis (PSA) was undertaken in some studies, but the distributions used for PSA were rarely reported or justified. The cost-effectiveness of follow-up strategies among people with confirmed adenomas are warranted in aiding evidence-informed decision making in response to the rapidly evolving technologies and rising expectations.
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Affiliation(s)
- Kim E Jeong
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - John A Cairns
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
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Dinh T, Ladabaum U, Alperin P, Caldwell C, Smith R, Levin TR. Health benefits and cost-effectiveness of a hybrid screening strategy for colorectal cancer. Clin Gastroenterol Hepatol 2013; 11:1158-66. [PMID: 23542330 DOI: 10.1016/j.cgh.2013.03.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 03/05/2013] [Accepted: 03/06/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Colorectal cancer (CRC) screening guidelines recommend screening schedules for each single type of test except for concurrent sigmoidoscopy and fecal occult blood test (FOBT). We investigated the cost-effectiveness of a hybrid screening strategy that was based on a fecal immunological test (FIT) and colonoscopy. METHODS We conducted a cost-effectiveness analysis by using the Archimedes Model to evaluate the effects of different CRC screening strategies on health outcomes and costs related to CRC in a population that represents members of Kaiser Permanente Northern California. The Archimedes Model is a large-scale simulation of human physiology, diseases, interventions, and health care systems. The CRC submodel in the Archimedes Model was derived from public databases, published epidemiologic studies, and clinical trials. RESULTS A hybrid screening strategy led to substantial reductions in CRC incidence and mortality, gains in quality-adjusted life years (QALYs), and reductions in costs, comparable with those of the best single-test strategies. Screening by annual FIT of patients 50-65 years old and then a single colonoscopy when they were 66 years old (FIT/COLOx1) reduced CRC incidence by 72% and gained 110 QALYs for every 1000 people during a period of 30 years, compared with no screening. Compared with annual FIT, FIT/COLOx1 gained 1400 QALYs/100,000 persons at an incremental cost of $9700/QALY gained and required 55% fewer FITs. Compared with FIT/COLOx1, colonoscopy at 10-year intervals gained 500 QALYs/100,000 at an incremental cost of $35,100/QALY gained but required 37% more colonoscopies. Over the ranges of parameters examined, the cost-effectiveness of hybrid screening strategies was slightly more sensitive to the adherence rate with colonoscopy than the adherence rate with yearly FIT. Uncertainties associated with estimates of FIT performance within a program setting and sensitivities for flat and right-sided lesions are expected to have significant impacts on the cost-effectiveness results. CONCLUSIONS In our simulation model, a strategy of annual or biennial FIT, beginning when patients are 50 years old, with a single colonoscopy when they are 66 years old, delivers clinical and economic outcomes similar to those of CRC screening by single-modality strategies, with a favorable impact on resources demand.
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Affiliation(s)
- Tuan Dinh
- Archimedes Inc, San Francisco, California 94105, USA.
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Ladabaum U, Allen J, Wandell M, Ramsey S. Colorectal cancer screening with blood-based biomarkers: cost-effectiveness of methylated septin 9 DNA versus current strategies. Cancer Epidemiol Biomarkers Prev 2013; 22:1567-76. [PMID: 23796793 DOI: 10.1158/1055-9965.epi-13-0204] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Screening reduces colorectal cancer mortality, but many persons remain unscreened. Screening with a blood test could improve screening rates. We estimated the comparative effectiveness and cost-effectiveness of colorectal cancer screening with emerging biomarkers, illustrated by a methylated Septin 9 DNA plasma assay ((m)SEPT9), versus established strategies. METHODS We conducted a cost-utility analysis using a validated decision analytic model comparing (m)SEPT9, fecal occult blood testing (FOBT), fecal immunochemical testing (FIT), sigmoidoscopy, and colonoscopy, projecting lifetime benefits and costs. RESULTS In the base case, (m)SEPT9 decreased colorectal cancer incidence by 35% to 41% and colorectal cancer mortality by 53% to 61% at costs of $8,400 to $11,500/quality-adjusted life year gained versus no screening. All established screening strategies were more effective than (m)SEPT9. FIT was cost saving, dominated (m)SEPT9, and was preferred among all the alternatives. Screening uptake and longitudinal adherence rates over time strongly influenced the comparisons between strategies. At the population level, (m)SEPT9 yielded incremental benefit at acceptable costs when it increased the fraction of the population screened more than it was substituted for other strategies. CONCLUSIONS (m)SEPT9 seems to be effective and cost-effective compared with no screening. To be cost-effective compared with established strategies, (m)SEPT9 or blood-based biomarkers with similar test performance characteristics would need to achieve substantially higher uptake and adherence rates than the alternatives. It remains to be proven whether colorectal cancer screening with a blood test can improve screening uptake or long-term adherence compared with established strategies. IMPACT Our study offers insights into the potential role of colorectal cancer screening with blood-based biomarkers.
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Affiliation(s)
- Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305-5187, USA.
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COST-EFFECTIVENESS OF AN ADVANCE NOTIFICATION LETTER TO INCREASE COLORECTAL CANCER SCREENING. Int J Technol Assess Health Care 2013; 29:261-8. [DOI: 10.1017/s0266462313000226] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Objectives:The aim of this study is to evaluate the cost-effectiveness of a patient-direct mailed advance notification letter on participants of a National Bowel Cancer Screening Program (NBCSP) in Australia, which was launched in August 2006 and offers free fecal occult blood testing to all Australians turning 50, 55, or 65 years of age in any given year.Methods:This study followed a hypothetical cohort of 50-year-old, 55-year-old, and 65-year-old patients undergoing fecal occult blood test (FOBT) screening through a decision analytic Markov model. The intervention compared two strategies: (i) advance letter, NBCSP, and FOBT compared with (ii) NBCSP and FOBT. The main outcome measures were life-years gained (LYG), quality-adjusted life-years (QALYs) gained and incremental cost-effectiveness ratio.Results:An advance notification screening letter would yield an additional 54 per 100,000 colorectal cancer deaths avoided compared with no letter. The estimated cost-effectiveness was $3,976 per LYG and $6,976 per QALY gained.Conclusions:An advance notification letter in the NBCSP may have a significant impact on LYG and cancer deaths avoided. It is cost-effective and offers a feasible strategy that could be rolled out across other screening program at an acceptable cost.
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Tran B, Keating CL, Ananda SS, Kosmider S, Jones I, Croxford M, Field KM, Carter RC, Gibbs P. Preliminary analysis of the cost-effectiveness of the National Bowel Cancer Screening Program: demonstrating the potential value of comprehensive real world data. Intern Med J 2013; 42:794-800. [PMID: 21883782 DOI: 10.1111/j.1445-5994.2011.02585.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND/AIM The complexity and cost of treating cancer patients is escalating rapidly and increasingly difficult decisions are being made regarding which interventions provide value for money. BioGrid Australia supports collection and analysis of comprehensive treatment and outcome data across multiple sites. Here, we use preliminary data regarding the National Bowel Cancer Screening Program (NBCSP) and stage-specific treatment costs for colorectal cancer (CRC) to demonstrate the potential value of real world data for cost-effectiveness analyses (CEA). METHODS Data regarding the impact of NBCSP on stage at diagnosis were combined with stage-specific CRC treatment costs and existing literature. An incremental CEA was undertaken from a government healthcare perspective, comparing NBCSP with no screening. The 2008 invited population (n= 681,915) was modelled in both scenarios. Effectiveness was expressed as CRC-related life years saved (LYS). Costs and benefits were discounted at 3% per annum. RESULTS Over the lifetime and relative to no screening, NBCSP was predicted to save 1265 life years, prevent 225 CRC cases and cost an additional $48.3 million, equivalent to a cost-effectiveness ratio of $38,217 per LYS. A scenario analysis assuming full participation improved this to $23,395. CONCLUSIONS This preliminary CEA based largely on contemporary real world data suggests population-based faecal occult blood test screening for CRC is attractive. Planned ongoing data collection will enable repeated analyses over time, using the same methodology in the same patient populations, permitting an accurate analysis of the impact of new therapies and changing practice. Similar CEA using real world data related to other disease types and interventions appears desirable.
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Affiliation(s)
- B Tran
- Royal Melbourne Hospital, Parkville, Victoria, Australia.
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Brenner H, Altenhofen L, Stock C, Hoffmeister M. Natural history of colorectal adenomas: birth cohort analysis among 3.6 million participants of screening colonoscopy. Cancer Epidemiol Biomarkers Prev 2013; 22:1043-51. [PMID: 23632815 DOI: 10.1158/1055-9965.epi-13-0162] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Most colorectal cancers (CRC) develop from adenomas. Knowledge of the natural history of colorectal adenomas, which is not directly observable for ethical reasons, is crucial for designing cost-effective CRC screening strategies. METHODS We derived transition rates from carriage of nonadvanced adenoma to carriage of advanced adenoma to carriage of CRC by sex and age in birth cohort analyses among 3,593,420 participants in the German screening colonoscopy program in 2003-2010. RESULTS Transition rates from advanced adenoma to CRC carriage were similar in men and women, but monotonically and significantly increased with age. Estimated annual transition percentages [(95% confidence interval (CI)] in age groups 55-59, 60-64, 65-69, 70-74, and 75-79 years were 2.6 (2.4-2.9), 3.1 (2.8-3.3), 3.8 (3.5-4.1), 5.1 (4.8-5.5), and 5.2 (4.6-5.8) among men, and 2.5 (2.2-2.7), 2.7 (2.4-3.0), 3.8 (3.5-4.1), 5.0 (4.5-5.4), and 5.6 (4.9-6.3) among women. Estimated annual transitions from carriage of nonadvanced to carriage of advanced adenoma were in a narrow range from 3.6% to 4.7% for all age and sex groups. CONCLUSIONS Despite low annual transition rates, cumulative transition rates from advanced adenoma to CRC carriage are expected to exceed by 60%, 50%, and 40% for age intervals 55-80, 65-80, and 70-80 years, respectively, in both sexes. Cumulative transition rates from nonadvanced adenoma to CRC carriage are expected to be close to 30% for age interval 55-80 years, but less than 2% for age interval 75-80 years. IMPACT Our results enhance the empirical basis for modeling CRC screening strategies.
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Affiliation(s)
- Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.
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Management of colon cancer: resource-stratified guidelines from the Asian Oncology Summit 2012. Lancet Oncol 2013; 13:e470-81. [PMID: 23117002 DOI: 10.1016/s1470-2045(12)70424-2] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Colon cancer is seen with increasing frequency in the Asia-Pacific region, and it is one of the most important causes of cancer mortality worldwide. This article reviews the available evidence for optimum management of colon cancer-in particular, with respect to screening and early detection of colon cancer, laparoscopic surgical treatment, adjuvant treatment of individuals with high-risk stage II and stage III cancer, palliative treatment of patients with metastatic disease, and management of resectable and potentially resectable metastases-and how these strategies can be applied in Asian countries with different levels of health-care resources and economic development, stratified by basic, limited, enhanced, and maximum resource levels.
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van Dam L, Kuipers EJ, Steyerberg EW, van Leerdam ME, de Beaufort ID. The price of autonomy: should we offer individuals a choice of colorectal cancer screening strategies? Lancet Oncol 2013; 14:e38-46. [DOI: 10.1016/s1470-2045(12)70455-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Trikalinos TA, Kulasingam S, Lawrence WF. Chapter 10: deciding whether to complement a systematic review of medical tests with decision modeling. J Gen Intern Med 2012; 27 Suppl 1:S76-82. [PMID: 22648678 PMCID: PMC3364358 DOI: 10.1007/s11606-012-2019-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Limited by what is reported in the literature, most systematic reviews of medical tests focus on "test accuracy" (or better, test performance), rather than on the impact of testing on patient outcomes. The link between testing, test results and patient outcomes is typically complex: even when testing has high accuracy, there is no guarantee that physicians will act according to test results, that patients will follow their orders, or that the intervention will yield a beneficial endpoint. Therefore, test performance is typically not sufficient for assessing the usefulness of medical tests. Modeling (in the form of decision or economic analysis) is a natural framework for linking test performance data to clinical outcomes. We propose that (some) modeling should be considered to facilitate the interpretation of summary test performance measures by connecting testing and patient outcomes. We discuss a simple algorithm for helping systematic reviewers think through this possibility, and illustrate it by means of an example.
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Affiliation(s)
- Thomas A Trikalinos
- Center for Evidence-based Medicine, and Department of Health Services Policy and Practice, Brown University, Providence, RI 02912, USA.
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Impact of comorbidity on colorectal cancer screening cost-effectiveness study in diabetic populations. J Gen Intern Med 2012; 27:730-8. [PMID: 22237663 PMCID: PMC3358394 DOI: 10.1007/s11606-011-1972-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 12/02/2011] [Accepted: 12/08/2011] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although comorbidity has been shown to affect the benefits and risks of colorectal cancer (CRC) screening, it has not been accounted for in prior cost-effectiveness analyses of CRC screening. OBJECTIVE To evaluate the impact of diagnosis of diabetes mellitus, a highly prevalent comorbidity in U.S. adults aged 50 and older, on health and economic outcomes of CRC screening. DESIGN Cost-effectiveness analysis using an integrated modeling framework. DATA SOURCES Derived from basic and epidemiologic studies, clinical trials, cancer registries, and a colonoscopy database. TARGET POPULATION U.S. 50-year-old population. TIME HORIZON Lifetime. PERSPECTIVE Costs are based on Medicare reimbursement rates. INTERVENTIONS Colonoscopy screening at ten-year intervals, beginning at age 50, and discontinued after age 50, 60, 70, 80 or death. OUTCOME MEASURES Health outcomes and cost effectiveness. RESULTS OF BASE-CASE ANALYSIS Diabetes diagnosis significantly affects cost-effectiveness of CRC screening. For the same CRC screening strategy, a person without diabetes at age 50 gained on average 0.07-0.13 life years more than a person diagnosed with diabetes at age 50 or younger. For a population of 1,000 patients diagnosed with diabetes at baseline, increasing stop age from 70 years to 80 years increased quality-adjusted life years (QALYs) gained by 0.3, with an incremental cost-effectiveness ratio of $206,671/QALY. The corresponding figures for 1,000 patients without diabetes are 2.3 QALYs and $46,957/QALY. RESULTS OF SENSITIVITY ANALYSIS Cost-effectiveness results are sensitive to cost of colonoscopy and adherence to colonoscopy screening. LIMITATIONS Results depend on accuracy of model assumptions. CONCLUSION Benefits of CRC screening differ substantially for patients with and without diabetes. Screening for CRC in patients diagnosed with diabetes at age 50 or younger is not cost-effective beyond age 70. Screening recommendations should be individualized based on the presence of comorbidities.
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Lansdorp-Vogelaar I, Kuntz KM, Knudsen AB, van Ballegooijen M, Zauber AG, Jemal A. Contribution of screening and survival differences to racial disparities in colorectal cancer rates. Cancer Epidemiol Biomarkers Prev 2012; 21:728-36. [PMID: 22514249 PMCID: PMC3531983 DOI: 10.1158/1055-9965.epi-12-0023] [Citation(s) in RCA: 154] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Considerable disparities exist in colorectal cancer (CRC) incidence and mortality rates between blacks and whites in the United States. We estimated how much of these disparities could be explained by differences in CRC screening and stage-specific relative CRC survival. METHODS We used the MISCAN-Colon microsimulation model to estimate CRC incidence and mortality rates in blacks, aged 50 years and older, from 1975 to 2007 assuming they had: (i) the same trends in screening rates as whites instead of observed screening rates (incidence and mortality); (ii) the same trends in stage-specific relative CRC survival rates as whites instead of observed (mortality only); and (iii) a combination of both. The racial disparities in CRC incidence and mortality rates attributable to differences in screening and/or stage-specific relative CRC survival were then calculated by comparing rates from these scenarios to the observed black rates. RESULTS Differences in screening accounted for 42% of disparity in CRC incidence and 19% of disparity in CRC mortality between blacks and whites. Thirty-six percent of the disparity in CRC mortality could be attributed to differences in stage-specific relative CRC survival. Together screening and survival explained a little more than 50% of the disparity in CRC mortality between blacks and whites. CONCLUSION Differences in screening and relative CRC survival are responsible for a considerable proportion of the observed disparities in CRC incidence and mortality rates between blacks and whites. IMPACT Enabling blacks to achieve equal access to care as whites could substantially reduce the racial disparities in CRC burden.
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Mobley LR, Subramanian S, Koschinsky J, Frech HE, Trantham LC, Anselin L. Managed care and the diffusion of endoscopy in fee-for-service Medicare. Health Serv Res 2011; 46:1905-27. [PMID: 22092022 PMCID: PMC3227000 DOI: 10.1111/j.1475-6773.2011.01301.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To determine whether Medicare managed care penetration impacted the diffusion of endoscopy services (sigmoidoscopy, colonoscopy) among the fee-for-service (FFS) Medicare population during 2001-2006. METHODS We model utilization rates for colonoscopy or sigmoidoscopy as impacted by both market supply and demand factors. We use spatial regression to perform ecological analysis of county-area utilization rates over two time intervals (2001-2003, 2004-2006) following Medicare benefits expansion in 2001 to cover colonoscopy for persons of average risk. We examine each technology in separate cross-sectional regressions estimated over early and later periods to assess differential effects on diffusion over time. We discuss selection factors in managed care markets and how failure to control perfectly for market selection might impact our managed care spillover estimates. RESULTS Areas with worse socioeconomic conditions have lower utilization rates, especially for colonoscopy. Holding constant statistically the socioeconomic factors, we find that managed care spillover effects onto FFS Medicare utilization rates are negative for colonoscopy and positive for sigmoidoscopy. The spatial lag estimates are conservative and interpreted as a lower bound on true effects. Our findings suggest that managed care presence fostered persistence of the older technology during a time when it was rapidly being replaced by the newer technology.
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Brenner H, Altenhofen L, Katalinic A, Lansdorp-Vogelaar I, Hoffmeister M. Sojourn time of preclinical colorectal cancer by sex and age: estimates from the German national screening colonoscopy database. Am J Epidemiol 2011; 174:1140-6. [PMID: 21984657 DOI: 10.1093/aje/kwr188] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The sojourn time of preclinical colorectal cancer is a critical parameter in modeling effectiveness and cost-effectiveness of colorectal cancer screening. For ethical reasons, it cannot be observed directly, and available estimates are based mostly on relatively small historic data sets that do not include differentiation by age and sex. The authors derived sex- and age-specific estimates (age groups: 55-59, 60-64, 65-69, 70-74, 75-79, and ≥80 years) of mean sojourn time, combining data from the German national screening colonoscopy registry (based on 1.88 million records) and data from population-based cancer registries (population base: 37.9 million people) for the years 2003-2006. Estimates of mean sojourn time were similar for both sexes and all age groups and ranged from 4.5 years (95% confidence interval: 4.1, 4.8) to 5.8 years (95% confidence interval: 5.3, 6.3) for the subgroups assessed. Sensitivity analyses indicated that mean sojourn time might be approximately 1.5 years longer if colorectal cancer prevalence in nonparticipants of screening colonoscopy is 20% lower than prevalence in participants or 1 year shorter if it exceeds the prevalence in participants by 20%. This study provides, for the first time, precise estimates of sojourn time by age and sex, and it suggests that sojourn times are remarkably consistent across age groups and in both sexes.
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Affiliation(s)
- Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer ResearchCenter, Im Neuenheimer Feld 581, Heidelberg, Germany.
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Hol L, Kuipers EJ, van Ballegooijen M, van Vuuren AJ, Reijerink JC, Habbema DJ, van Leerdam ME. Uptake of faecal immunochemical test screening among nonparticipants in a flexible sigmoidoscopy screening programme. Int J Cancer 2011; 130:2096-102. [DOI: 10.1002/ijc.26260] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Accepted: 01/10/2011] [Indexed: 12/31/2022]
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Vanness DJ, Knudsen AB, Lansdorp-Vogelaar I, Rutter CM, Gareen IF, Herman BA, Kuntz KM, Zauber AG, van Ballegooijen M, Feuer EJ, Chen MH, Johnson CD. Comparative economic evaluation of data from the ACRIN National CT Colonography Trial with three cancer intervention and surveillance modeling network microsimulations. Radiology 2011; 261:487-98. [PMID: 21813740 DOI: 10.1148/radiol.11102411] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE To estimate the cost-effectiveness of computed tomographic (CT) colonography for colorectal cancer (CRC) screening in average-risk asymptomatic subjects in the United States aged 50 years. MATERIALS AND METHODS Enrollees in the American College of Radiology Imaging Network National CT Colonography Trial provided informed consent, and approval was obtained from the institutional review board at each site. CT colonography performance estimates from the trial were incorporated into three Cancer Intervention and Surveillance Modeling Network CRC microsimulations. Simulated survival and lifetime costs for screening 50-year-old subjects in the United States with CT colonography every 5 or 10 years were compared with those for guideline-concordant screening with colonoscopy, flexible sigmoidoscopy plus either sensitive unrehydrated fecal occult blood testing (FOBT) or fecal immunochemical testing (FIT), and no screening. Perfect and reduced screening adherence scenarios were considered. Incremental cost-effectiveness and net health benefits were estimated from the U.S. health care sector perspective, assuming a 3% discount rate. RESULTS CT colonography at 5- and 10-year screening intervals was more costly and less effective than FOBT plus flexible sigmoidoscopy in all three models in both 100% and 50% adherence scenarios. Colonoscopy also was more costly and less effective than FOBT plus flexible sigmoidoscopy, except in the CRC-SPIN model assuming 100% adherence (incremental cost-effectiveness ratio: $26,300 per life-year gained). CT colonography at 5- and 10-year screening intervals and colonoscopy were net beneficial compared with no screening in all model scenarios. The 5-year screening interval was net beneficial over the 10-year interval except in the MISCAN model when assuming 100% adherence and willingness to pay $50,000 per life-year gained. CONCLUSION All three models predict CT colonography to be more costly and less effective than non-CT colonographic screening but net beneficial compared with no screening given model assumptions.
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Affiliation(s)
- David J Vanness
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, 610 Walnut St, Madison, WI 53726, USA.
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Wilschut JA, Steyerberg EW, van Leerdam ME, Lansdorp-Vogelaar I, Habbema JDF, van Ballegooijen M. How much colonoscopy screening should be recommended to individuals with various degrees of family history of colorectal cancer? Cancer 2011; 117:4166-74. [PMID: 21387272 DOI: 10.1002/cncr.26009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 12/17/2010] [Accepted: 02/01/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Individuals with a family history of colorectal cancer (CRC) are at increased risk for CRC. Current screening recommendations for these individuals are based on expert opinion. The authors investigated optimal screening strategies for individuals with various degrees of family history of CRC based on a cost-effectiveness analysis. METHODS The MISCAN-Colon microsimulation model was used to estimate costs and effects of CRC screening strategies, varying by the age at which screening was started and stopped and by screening interval. The authors defined 4 risk groups, characterized by the number of affected first-degree relatives and their age at CRC diagnosis. For all risk groups, the optimal screening strategy had an incremental cost-effectiveness ratio of approximately $50,000 per life-year gained. RESULTS The optimal screening strategy for individuals with 1 first-degree relative diagnosed after age 50 years was 6 colonoscopies every 5 years starting at age 50 years, compared with 4 colonoscopies every 7 years starting at age 50 years for average risk individuals. The optimal strategy had 10 colonoscopies every 4 years for individuals with 1 first-degree relative diagnosed before age 50 years, 13 colonoscopies every 3 years for individuals with 2 or more first-degree relatives diagnosed after age 50 years, and 15 colonoscopies every 3 years for individuals with 2 or more first-degree relatives of whom at least 1 was diagnosed before age 50 years. CONCLUSIONS The optimal screening strategy varies considerably with the number of affected first-degree relatives and their age of diagnosis. Shorter screening intervals than the currently recommended 5 years may be appropriate for the highest risk individuals.
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Affiliation(s)
- Janneke A Wilschut
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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Moiel D, Thompson J. Early detection of colon cancer-the kaiser permanente northwest 30-year history: how do we measure success? Is it the test, the number of tests, the stage, or the percentage of screen-detected patients? Perm J 2011; 15:30-8. [PMID: 22319413 PMCID: PMC3267557 DOI: 10.7812/tpp/11-128] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Colorectal cancer (CRC) is the fourth most common malignancy in the Kaiser Permanente Northwest (KPNW) Region. The goals of CRC screening are early diagnosis of cancer in the preclinical state, down-staging of tumors, and increasing survival. This historical review summarizes the screening strategies since 1980 and their impact on early diagnosis, stage, and survival. During this period, the KPNW Tumor Registry documented the stage and survival, and screen-detection status of patients. We have observed that the percentage of screen-detected case measure has provided critical information that has contributed to the present success. CRC screening efforts by the end of 2010 had provided early diagnosis for one-third of patients. METHODS KPNW membership has undergone more than 540,000 fecal blood tests, an estimated 130,000 flexible sigmoidoscopies (FS), and more than 100,000 colonoscopies. Since 1980 members older than age 50 years have increased from 48,627 to 137,617. This report represents a review of 5458 patients. Since 1980, 5 distinct periods of CRC screening have been compared. In 1980, the CRC screening practice was primarily office-based fecal occult blood testing (FOBT) and proctosigmoidoscopy. Data from the initial home-based FOBT testing initiative (1985), transitioning to an FS program (1995), adoption of colonoscopy (2005), and subsequent reintroduction of FOBT testing (2006) allows examination of results by period. After ever-increasing promotion of endoscopy, the goal of screening shifted from "screen detection to prevention by polypectomy." RESULTS By reexamining the outcomes of the CRC strategies from 1980-2005, the nature of the colonoscopy label of "gold standard" was questioned leading to a return to FOBT testing. Since then, the percentage of screen-detected patients exceeded expectations with a 6-fold increase (5% to 33%) allowing KPNW to reach its highest level of early detection. DISCUSSION By examining the KPNW experience, we have come to better understand the significance of effectiveness measures: number of tests, stage of disease, percentage of screen-detected cancers and their relationship to survival. We examined the measures used to assess success and conclude that the current metrics-the number of examinations and disease stage-do not accurately reflect the effectiveness of screening efforts. Early detection of CRC saves lives when a program tests the most at-risk people. Using a good test (FOBT/fecal immunochemical test) that is able to reach more people, rather than the "perfect test" that reaches fewer people, transforms an ineffective program into a successful one. A critical element was the transition of the individual testing to population screening.
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Gopalappa C, Aydogan-Cremaschi S, Das TK, Orcun S. Probability model for estimating colorectal polyp progression rates. Health Care Manag Sci 2010; 14:1-21. [DOI: 10.1007/s10729-010-9138-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2009] [Accepted: 09/13/2010] [Indexed: 12/12/2022]
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Lansdorp-Vogelaar I, Kuntz KM, Knudsen AB, Wilschut JA, Zauber AG, van Ballegooijen M. Stool DNA testing to screen for colorectal cancer in the Medicare population: a cost-effectiveness analysis. Ann Intern Med 2010. [PMID: 20855801 DOI: 10.1059/0003-4819-153-6-201009210-00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services considered whether to reimburse stool DNA testing for colorectal cancer screening among Medicare enrollees. OBJECTIVE To evaluate the conditions under which stool DNA testing could be cost-effective compared with the colorectal cancer screening tests currently reimbursed by the Centers for Medicare & Medicaid Services. DESIGN Comparative microsimulation modeling study using 2 independently developed models. DATA SOURCES Derived from literature. TARGET POPULATION A cohort of persons aged 65 years. A sensitivity analysis was also conducted, in which a cohort of persons aged 50 years was studied. TIME HORIZON Lifetime. PERSPECTIVE Third-party payer. INTERVENTION Stool DNA test every 3 or 5 years in comparison with currently recommended colorectal cancer screening strategies. OUTCOME MEASURES Life expectancy, lifetime costs, incremental cost-effectiveness ratios, and threshold costs. RESULTS OF BASE-CASE ANALYSIS Assuming a cost of $350 per test, strategies of stool DNA testing every 3 or 5 years yielded fewer life-years and higher costs than the currently recommended colorectal cancer screening strategies. Screening with the stool DNA test would be cost-effective at a per-test cost of $40 to $60 for stool DNA testing every 3 years, depending on the simulation model used. There were no levels of sensitivity and specificity for which stool DNA testing would be cost-effective at its current cost of $350 per test. Stool DNA testing every 3 years would be cost-effective at a cost of $350 per test if the relative adherence to stool DNA testing were at least 50% better than that with other screening tests. RESULTS OF SENSITIVITY ANALYSIS None of the results changed substantially when a cohort of persons aged 50 years was considered. LIMITATION No pathways other than the traditional adenoma-carcinoma sequence were modeled. CONCLUSION Stool DNA testing could be a cost-effective alternative for colorectal cancer screening if the cost of the test substantially decreased or if its availability would entice a large fraction of otherwise unscreened persons to receive screening.
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Brenner H, Altenhofen L, Hoffmeister M. Estimated long-term effects of the initial 6 years of the German screening colonoscopy program. Gastrointest Endosc 2010; 72:784-9. [PMID: 20883856 DOI: 10.1016/j.gie.2010.06.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2010] [Accepted: 06/03/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Colorectal cancer is the most common cancer in Germany. Screening colonoscopies have been offered as a primary screening tool in Germany since the end of 2002. OBJECTIVE To estimate the numbers of clinically manifest colorectal cancers prevented by detection and removal of advanced adenomas in the initial 6 years of the program. DESIGN Markov model with single-year transitions. SETTING German screening colonoscopy program. PATIENTS Participants in the screening colonoscopy program from 2003 to 2008. INTERVENTIONS Screening colonoscopy with the removal of advanced colorectal neoplasms. MAIN OUTCOME MEASUREMENTS The expected numbers of incident colorectal cancers prevented by detection and removal of advanced adenomas. RESULTS An estimated total number of 73,024 cases of colorectal cancer might have developed from the removed advanced adenomas and become clinically manifest between 55 and 84 years of age in the absence of screening colonoscopy. This number exceeds the number of colorectal cancers diagnosed in 2002 by 27%. Among prevented cancers, 8%, 43%, and 49% would have occurred at ages 55 to 64, 65 to 74, and 75 to 84 years (median age 74 years), respectively; 60% and 40% would have occurred among men and women, respectively; and 22%, 32%, 25%, and 20% would have occurred within 1 to 5, 6 to 10, 11 to 15, and 16 to 30 years, respectively, after colonoscopy (median 10 years). LIMITATIONS Diagnoses of advanced adenomas are based on records from a large number of endoscopists and pathology laboratories. CONCLUSIONS Despite relatively low screening participation, the German screening colonoscopy program is expected to make a major contribution to the prevention of colorectal cancer, even though most of the impact will only be seen in the longer run.
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Affiliation(s)
- Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
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Brenner H, Altenhofen L, Hoffmeister M. Eight years of colonoscopic bowel cancer screening in Germany: initial findings and projections. DEUTSCHES ARZTEBLATT INTERNATIONAL 2010; 107:753-9. [PMID: 21085544 PMCID: PMC2982991 DOI: 10.3238/arztebl.2010.0753] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Accepted: 06/28/2010] [Indexed: 12/31/2022]
Abstract
BACKGROUND Screening colonoscopy has been offered in Germany since the end of 2002. Our aim was to estimate numbers of colorectal cancers prevented or detected early by screening colonoscopy in 2003-2010. METHODS Participation rates and prevalences of advanced adenomas and colorectal cancers at screening colonoscopy in 2003-2008 were obtained from the national screening colonoscopy database by age, sex and calendar year. For 2009 and 2010, levels were assumed to remain at those observed in 2008. These data were combined in Markov models with population figures and estimates of transition rates from advanced adenomas to preclinical colorectal cancer and from preclinical cancer to clinically manifest cancer, accounting for total mortality. RESULTS An estimated total number of 98 734 cases of colorectal cancer at ages 55-84 years are expected to have been prevented in Germany by removal of advanced adenomas by the end of 2010. These cancers might have become clinically manifest a median time period of 10 years after screening colonoscopy. Another 47 168 cases are expected to have been detected early at screening colonoscopy, often in a curable stage. CONCLUSION Despite limited participation, the German screening colonoscopy program makes a major contribution to prevention and early detection of colorectal cancer.
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Affiliation(s)
- Hermann Brenner
- Abteilung Klinische Epidemiologie und Alternsforschung, Deutsches Kresbforschungszentrum, Bergheimer Str. 20, 69115 Heidelberg, Germany.
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Lansdorp-Vogelaar I, Kuntz KM, Knudsen AB, Wilschut JA, Zauber AG, van Ballegooijen M. Stool DNA testing to screen for colorectal cancer in the Medicare population: a cost-effectiveness analysis. Ann Intern Med 2010; 153:368-77. [PMID: 20855801 PMCID: PMC3578600 DOI: 10.7326/0003-4819-153-6-201009210-00004] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services considered whether to reimburse stool DNA testing for colorectal cancer screening among Medicare enrollees. OBJECTIVE To evaluate the conditions under which stool DNA testing could be cost-effective compared with the colorectal cancer screening tests currently reimbursed by the Centers for Medicare & Medicaid Services. DESIGN Comparative microsimulation modeling study using 2 independently developed models. DATA SOURCES Derived from literature. TARGET POPULATION A cohort of persons aged 65 years. A sensitivity analysis was also conducted, in which a cohort of persons aged 50 years was studied. TIME HORIZON Lifetime. PERSPECTIVE Third-party payer. INTERVENTION Stool DNA test every 3 or 5 years in comparison with currently recommended colorectal cancer screening strategies. OUTCOME MEASURES Life expectancy, lifetime costs, incremental cost-effectiveness ratios, and threshold costs. RESULTS OF BASE-CASE ANALYSIS Assuming a cost of $350 per test, strategies of stool DNA testing every 3 or 5 years yielded fewer life-years and higher costs than the currently recommended colorectal cancer screening strategies. Screening with the stool DNA test would be cost-effective at a per-test cost of $40 to $60 for stool DNA testing every 3 years, depending on the simulation model used. There were no levels of sensitivity and specificity for which stool DNA testing would be cost-effective at its current cost of $350 per test. Stool DNA testing every 3 years would be cost-effective at a cost of $350 per test if the relative adherence to stool DNA testing were at least 50% better than that with other screening tests. RESULTS OF SENSITIVITY ANALYSIS None of the results changed substantially when a cohort of persons aged 50 years was considered. LIMITATION No pathways other than the traditional adenoma-carcinoma sequence were modeled. CONCLUSION Stool DNA testing could be a cost-effective alternative for colorectal cancer screening if the cost of the test substantially decreased or if its availability would entice a large fraction of otherwise unscreened persons to receive screening.
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Mobley LR, Kuo TM, Urato M, Subramanian S. Community contextual predictors of endoscopic colorectal cancer screening in the USA: spatial multilevel regression analysis. Int J Health Geogr 2010; 9:44. [PMID: 20815882 PMCID: PMC2941747 DOI: 10.1186/1476-072x-9-44] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Accepted: 09/03/2010] [Indexed: 11/10/2022] Open
Abstract
Background Colorectal cancer (CRC) is the second leading cause of cancer death in the United States, and endoscopic screening can both detect and prevent cancer, but utilization is suboptimal and varies across geographic regions. We use multilevel regression to examine the various predictors of individuals' decisions to utilize endoscopic CRC screening. Study subjects are a 100% population cohort of Medicare beneficiaries identified in 2001 and followed through 2005. The outcome variable is a binary indicator of any sigmoidoscopy or colonoscopy use over this period. We analyze each state separately and map the findings for all states together to reveal patterns in the observed heterogeneity across states. Results We estimate a fully adjusted model for each state, based on a comprehensive socio-ecological model. We focus the discussion on the independent contributions of each of three community contextual variables that are amenable to policy intervention. Prevalence of Medicare managed care in one's neighborhood was associated with lower probability of screening in 12 states and higher probability in 19 states. Prevalence of poor English language ability among elders in one's neighborhood was associated with lower probability of screening in 15 states and higher probability in 6 states. Prevalence of poverty in one's neighborhood was associated with lower probability of screening in 36 states and higher probability in 5 states. Conclusions There are considerable differences across states in the socio-ecological context of CRC screening by endoscopy, suggesting that the current decentralized configuration of state-specific comprehensive cancer control programs is well suited to respond to the observed heterogeneity. We find that interventions to mediate language barriers are more critically needed in some states than in others. Medicare managed care penetration, hypothesized to affect information about and diffusion of new endoscopic technologies, has a positive association in only a minority of states. This suggests that managed care plans' promotion of this cost-increasing technology has been rather limited. Area poverty has a negative impact in the vast majority of states, but is positive in five states, suggesting there are some effective cancer control policies in place targeting the poor with supplemental resources promoting CRC screening.
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Affiliation(s)
- Lee R Mobley
- RTI International, Discovery and Analytical Sciences Division, 3040 Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709-2194, USA.
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Ladabaum U, Ferrandez A, Lanas A. Cost-effectiveness of colorectal cancer screening in high-risk Spanish patients: use of a validated model to inform public policy. Cancer Epidemiol Biomarkers Prev 2010; 19:2765-76. [PMID: 20810603 DOI: 10.1158/1055-9965.epi-10-0530] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The European Community has made a commitment to colorectal cancer (CRC) screening, but regional considerations may affect the design of national screening programs. We developed a decision analytic model tailored to a pilot screening program for high-risk persons in Spain with the aim of informing public policy decisions. MATERIALS AND METHODS We constructed a decision analytic Markov model based on our validated model of CRC screening that reflected CRC epidemiology and costs in persons with first-degree relatives with CRC in Aragón, Spain, and superimposed colonoscopy every 5 or 10 years from ages 40 to 80 years. The pilot program's preliminary clinical results and our modeling results were presented to regional health authorities. RESULTS In the model, without screening, 88 CRC cases occurred per 1,000 persons from age 40 to 85 years. In the base case, screening reduced this by 72% to 77% and gained 0.12 discounted life years per person. Screening every 10 years was cost saving, and screening every 5 years versus every 10 years cost 7,250 euros per life year gained. Based on these savings, 36 to 39 euros per person per year could go toward operating costs while maintaining a neutral budget. If screening costs doubled, screening remained highly cost-effective but no longer cost saving. These results contributed to the health authorities' decision to expand the pilot program to the entire region in 2009. CONCLUSIONS Colonoscopic screening of first-degree relatives of persons with CRC may be cost saving in public systems like that of Spain. Decision analytic modeling tailored to regional considerations can inform public policy decisions. IMPACT Tailored decision analytic modeling can inform regional policy decisions on cancer screening.
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Affiliation(s)
- Uri Ladabaum
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, USA.
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Hawkes EA, Cunningham D. Flexible sigmoidoscopy--valuable in colorectal cancer. Nat Rev Clin Oncol 2010; 7:488-90. [PMID: 20798698 DOI: 10.1038/nrclinonc.2010.102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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van Ballegooijen M, Boer R, Zauber AG. Simulation of colorectal cancer screening: what we do and do not know and does it matter. Best Pract Res Clin Gastroenterol 2010; 24:427-37. [PMID: 20833347 PMCID: PMC4197829 DOI: 10.1016/j.bpg.2010.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Accepted: 07/01/2010] [Indexed: 01/31/2023]
Abstract
Simulation modelling is increasingly used to inform decision-making on screening, including colorectal cancer screening strategies. The strength of simulation is its ability to handle complexity and to identify the implications of uncertainty in a formal, documented, reproducible and consistent way. Important specific uncertainties concerning colorectal cancer screening are the dwell time of adenomas and the associated sensitivity of the various tests. Concerning these issues, for distal colorectal neoplasia, knowledge has been greatly increased by the recent availability of the once only sigmoidoscopy randomised trial results. Other uncertainties concern the quality of life effects of screening, diagnostic and surveillance colonoscopies, and the true total costs of the various screening modalities in a routine high throughput efficient setting. A limitation of simulation of screening is that complexity leads to lack of insight and understanding into the models used, and therefore a lack of sound criticism, acceptance and use amongst decision makers. Modellers are currently focussing on ways to make models and the implications of assumptions more transparent. Thus it is important to further develop the quality and acceptability of simulation, especially that for colorectal cancer screening.
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Affiliation(s)
| | - Rob Boer
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (MVB, RB)
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY (AGZ)
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A decision-analytic evaluation of the cost-effectiveness of family history-based colorectal cancer screening programs. Am J Gastroenterol 2010; 105:1861-9. [PMID: 20461066 DOI: 10.1038/ajg.2010.185] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to determine the cost-effectiveness of family history screening (FHS) for colorectal cancer (CRC) susceptibility at age 40 with early screening of those with increased risk. METHODS The cost-effectiveness of several family history-based screening programs was estimated with a validated microsimulation model, using data from the SEER cancer registry, life tables, medicare records, and published data. Familial cancer syndromes were excluded. Screening programs evaluated included (i) colonoscopy screening every 10 years starting at age 50 (no family history assessment); (ii) colonoscopy every 10 years from age 40 for persons with a family history; (iii) colonoscopy every 5 years from age 50 for those with a family history; and (iv) colonoscopy every 5 years from age 40 for persons with a family history. In each FHS scenario, persons without a family history are screened with colonoscopy at age 50, then every 10 years to age 80. RESULTS Compared with colonoscopy screening of all persons from age 50, the cost-effectiveness of the family history-based screening programs varied from $18,000-$51,000 per life year (LY) gained. Screening family history cases every 5 years from age 40 is more cost-effective than screening every 10 years from age 40. Reducing screening frequency for those without a family history lowers program expenditures substantially at a modest loss of LYs. The results are sensitive to the CRC risk difference between positive and negative family histories. CONCLUSIONS The cost-effectiveness of CRC FHS guidelines varies widely. Economic issues should be considered before implementing family history-directed screening programs.
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Atkin WS, Edwards R, Kralj-Hans I, Wooldrage K, Hart AR, Northover JMA, Parkin DM, Wardle J, Duffy SW, Cuzick J. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 2010; 375:1624-33. [PMID: 20430429 DOI: 10.1016/s0140-6736(10)60551-x] [Citation(s) in RCA: 1083] [Impact Index Per Article: 77.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Colorectal cancer is the third most common cancer worldwide and has a high mortality rate. We tested the hypothesis that only one flexible sigmoidoscopy screening between 55 and 64 years of age can substantially reduce colorectal cancer incidence and mortality. METHODS This randomised controlled trial was undertaken in 14 UK centres. 170 432 eligible men and women, who had indicated on a previous questionnaire that they would accept an invitation for screening, were randomly allocated to the intervention group (offered flexible sigmoidoscopy screening) or the control group (not contacted). Randomisation by sequential number generation was done centrally in blocks of 12, with stratification by trial centre, general practice, and household type. The primary outcomes were the incidence of colorectal cancer, including prevalent cases detected at screening, and mortality from colorectal cancer. Analyses were intention to treat and per protocol. The trial is registered, number ISRCTN28352761. FINDINGS 113 195 people were assigned to the control group and 57 237 to the intervention group, of whom 112 939 and 57 099, respectively, were included in the final analyses. 40 674 (71%) people underwent flexible sigmoidoscopy. During screening and median follow-up of 11.2 years (IQR 10.7-11.9), 2524 participants were diagnosed with colorectal cancer (1818 in control group vs 706 in intervention group) and 20 543 died (13 768 vs 6775; 727 certified from colorectal cancer [538 vs 189]). In intention-to-treat analyses, colorectal cancer incidence in the intervention group was reduced by 23% (hazard ratio 0.77, 95% CI 0.70-0.84) and mortality by 31% (0.69, 0.59-0.82). In per-protocol analyses, adjusting for self-selection bias in the intervention group, incidence of colorectal cancer in people attending screening was reduced by 33% (0.67, 0.60-0.76) and mortality by 43% (0.57, 0.45-0.72). Incidence of distal colorectal cancer (rectum and sigmoid colon) was reduced by 50% (0.50, 0.42-0.59; secondary outcome). The numbers needed to be screened to prevent one colorectal cancer diagnosis or death, by the end of the study period, were 191 (95% CI 145-277) and 489 (343-852), respectively. INTERPRETATION Flexible sigmoidoscopy is a safe and practical test and, when offered only once between ages 55 and 64 years, confers a substantial and longlasting benefit. FUNDING Medical Research Council, National Health Service R&D, Cancer Research UK, KeyMed.
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Affiliation(s)
- Wendy S Atkin
- Department of Surgery and Cancer, Imperial College London, London, UK.
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Tscheulin DK, Drevs F. The relevance of unrelated costs internal and external to the healthcare sector to the outcome of a cost-comparison analysis of secondary prevention: the case of general colorectal cancer screening in the German population. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2010; 11:141-150. [PMID: 19449159 DOI: 10.1007/s10198-009-0156-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2007] [Accepted: 04/24/2009] [Indexed: 05/27/2023]
Abstract
The potential of secondary prevention measures, such as cancer screening, to produce cost savings in the healthcare sector is a controversial issue in healthcare economics. Potential savings are calculated by comparing treatment costs with the cost of a prevention program. When survivors' subsequent unrelated health care costs are included in the calculation, however, the overall cost of disease prevention rises. What have not been studied to date are the secondary effects of fatal disease prevention measures on social security systems. From the perspective of a policy maker responsible for a social security system budget, it is not only future healthcare costs that are relevant for budgeting, but also changes in the contributions to, and expenditures from, statutory pension insurance and health insurance systems. An examination of the effect of longer life expectancies on these insurance systems can be justified by the fact that European social security systems are regulated by the state, and there is no clear separation between the financing of individual insurance systems due to cross-subsidisation. This paper looks at how the results of cost-comparison analyses vary depending on the inclusion or exclusion of future healthcare and non-healthcare costs, using the example of colorectal cancer screening in the German general population. In contrast to previous studies, not only are future unrelated medical costs considered, but also the effects on the social security system. If a German colorectal cancer screening program were implemented, and unrelated future medical care were excluded from the cost-benefit analysis, savings of up to 548 million euros per year would be expected. The screening program would, at the same time, generate costs in the healthcare sector as well as in the social security system of 2,037 million euros per year. Because the amount of future contributions and expenditures in the social security system depends on the age and gender of the recipients of the screening program (i.e. survivors of a typically fatal condition), the impact of age and gender on the results of a cost-comparison analysis of colorectal cancer screening are presented and discussed. Our study shows that colorectal cancer screening generates individual cost savings in the social security system up to a life expectancy of 60 years. Beyond that age, the balance between a recipient's social security contributions and insurance system expenditure is negative. The paper clarifies the relevance of healthcare costs not related to the prevented disease to the economic evaluation of prevention programs, particularly in the case of fatal diseases such as colorectal cancer. The results of the study imply that, from an economic perspective, the participation of at-risk individuals in disease prevention programs should be promoted.
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Affiliation(s)
- Dieter K Tscheulin
- Department of Marketing and Health Care Management, Albert-Ludwigs-Universität Freiburg, Platz der Alten Synagoge 1, 79085, Freiburg im Breisgau, Germany
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Abstract
Substantial progress has been made in colorectal cancer in the past decade. Screening, used to identify individuals at an early stage, has improved outcome. There is greater understanding of the genetic basis of inherited colorectal cancer and identification of patients at risk. Optimisation of surgery for patients with localised disease has had a major effect on survival at 5 years and 10 years. For rectal cancer, identification of patients at greatest risk of local failure is important in the selection of patients for preoperative chemoradiation, a strategy proven to improve outcomes in these patients. Stringent postoperative follow-up helps the early identification of potentially radically treatable oligometastatic disease and improves long-term survival. Treatment with adjuvant fluoropyrimidine for colon and rectal cancers further improves survival, more so in stage III than in stage II disease, and oxaliplatin-based combination chemotherapy is now routinely used for stage III disease, although efficacy must be carefully balanced against toxicity. In stage II disease, molecular markers such as microsatellite instability might help select patients for treatment. The integration of targeted treatments with conventional cytotoxic drugs has expanded the treatment of metastatic disease resulting in incremental survival gains. However, biomarker development is essential to aid selection of patients likely to respond to therapy, thereby rationalising treatments and improving outcomes.
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Affiliation(s)
- David Cunningham
- Gastrointestinal Unit, Royal Marsden Hospital National Health Service Foundation Trust, London and Surrey, UK.
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Ginsberg GM, Lim SS, Lauer JA, Johns BP, Sepulveda CR. Prevention, screening and treatment of colorectal cancer: a global and regional generalized cost effectiveness analysis. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2010; 8:2. [PMID: 20236531 PMCID: PMC2850877 DOI: 10.1186/1478-7547-8-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Accepted: 03/17/2010] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Regional generalized cost-effectiveness estimates of prevention, screening and treatment interventions for colorectal cancer are presented. METHODS Standardised WHO-CHOICE methodology was used. A colorectal cancer model was employed to provide estimates of screening and treatment effectiveness. Intervention effectiveness was determined via a population state-transition model (PopMod) that simulates the evolution of a sub-regional population accounting for births, deaths and disease epidemiology. Economic costs of procedures and treatment were estimated, including programme overhead and training costs. RESULTS In regions characterised by high income, low mortality and high existing treatment coverage, the addition of screening to the current high treatment levels is very cost-effective, although no particular intervention stands out in cost-effectiveness terms relative to the others.In regions characterised by low income, low mortality with existing treatment coverage around 50%, expanding treatment with or without screening is cost-effective or very cost-effective. Abandoning treatment in favour of screening (no treatment scenario) would not be cost effective.In regions characterised by low income, high mortality and low treatment levels, the most cost-effective intervention is expanding treatment. CONCLUSIONS From a cost-effectiveness standpoint, screening programmes should be expanded in developed regions and treatment programmes should be established for colorectal cancer in regions with low treatment coverage.
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Affiliation(s)
- Gary M Ginsberg
- Costs, Effectiveness, Expenditure and Priority Setting, World Health Organization, Geneva, Switzerland
| | - Stephen S Lim
- Costs, Effectiveness, Expenditure and Priority Setting, World Health Organization, Geneva, Switzerland
| | - Jeremy A Lauer
- Costs, Effectiveness, Expenditure and Priority Setting, World Health Organization, Geneva, Switzerland
| | - Benjamin P Johns
- Costs, Effectiveness, Expenditure and Priority Setting, World Health Organization, Geneva, Switzerland
| | - Cecilia R Sepulveda
- Chronic Diseases Prevention and Management, World Health Organization, Geneva, Switzerland
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Meng W, Cai SR, Zhou L, Dong Q, Zheng S, Zhang SZ. Performance value of high risk factors in colorectal cancer screening in China. World J Gastroenterol 2009; 15:6111-6. [PMID: 20027686 PMCID: PMC2797670 DOI: 10.3748/wjg.15.6111] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the performance value of high risk factors in population-based colorectal cancer (CRC) screening in China.
METHODS: We compared the performance value of the immunochemical fecal occult blood test (iFOBT) and other high risk factors questionnaire in a population sample of 13 214 community residents who completed both the iFOBT and questionnaire investigation. Patients with either a positive iFOBT and/or questionnaire were regarded as a high risk population and those eligible were asked to undergo colonoscopy.
RESULTS: The iFOBT had the highest positive predictive value and negative predictive value in screening for advanced neoplasia. The iFOBT had the highest sensitivity, lowest number of extra false positive results associated with the detection of one extra abnormality for screening advanced neoplasias and adenomas. A history of chronic cholecystitis or cholecystectomy, chronic appendicitis or appendectomy, and chronic diarrhea also had a higher sensitivity than a history of adenomatous polyps in screening for advanced neoplasias and adenomas. The sensitivity of a history of chronic cholecystitis or cholecystectomy was highest among the 10 high risk factors in screening for non-adenomatous polyps. A history of chronic appendicitis or appendectomy, chronic constipation, chronic diarrhea, mucous and bloody stool, CRC in first degree relatives, malignant tumor and a positive iFOBT also had higher sensitivities than a history of adenomas polyps in screening for non-adenomatous polyps. Except for a history of malignant tumor in screening for non-adenomatous polyps, the gain in sensitivity was associated with an increase in extra false positive results associated with the detection of one extra abnormality.
CONCLUSION: The iFOBT may be the best marker for screening for advanced neoplasias and adenomas. Some unique high risk factors may play an important role in CRC screening in China.
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Lansdorp-Vogelaar I, van Ballegooijen M, Zauber AG, Habbema JDF, Kuipers EJ. Effect of rising chemotherapy costs on the cost savings of colorectal cancer screening. J Natl Cancer Inst 2009; 101:1412-22. [PMID: 19779203 DOI: 10.1093/jnci/djp319] [Citation(s) in RCA: 141] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Although colorectal cancer screening is cost-effective, it requires a considerable net investment by governments or insurance companies. If screening was cost saving, governments and insurance companies might be more inclined to invest in colorectal cancer screening programs. We examined whether colorectal cancer screening would become cost saving with the widespread use of the newer, more expensive chemotherapies. METHODS We used the MISCAN-Colon microsimulation model to assess whether widespread use of new chemotherapies would affect the treatment savings of colorectal cancer screening in the general population. We considered three scenarios for chemotherapy use: the past, the present, and the near future. We assumed that survival improved and treatment costs for patients diagnosed with advanced stages of colorectal cancer increased over the scenarios. Screening strategies considered were annual guaiac fecal occult blood testing (FOBT), annual immunochemical FOBT, sigmoidoscopy every 5 years, colonoscopy every 10 years, and the combination of sigmoidoscopy every 5 years and annual guaiac FOBT. Analyses were conducted from the perspective of the health-care system for a cohort of 50-year-old individuals who were at average risk of colorectal cancer and were screened with 100% adherence from age 50 years to age 80 years and followed up until death. RESULTS Compared with no screening, the treatment savings from preventing advanced colorectal cancer and colorectal cancer deaths by screening more than doubled with the widespread use of new chemotherapies. The lifetime average treatment savings were larger than the lifetime average screening costs for screening with Hemoccult II, immunochemical FOBT, sigmoidoscopy, and the combination of sigmoidoscopy and Hemoccult II (average savings vs costs per individual in the population: Hemoccult II, $1398 vs $859; immunochemical FOBT, $1756 vs $1565; sigmoidoscopy, $1706 vs $1575; sigmoidoscopy and Hemoccult II $1931 vs $1878). Colonoscopy did not become cost saving, but the total net costs of this strategy decreased from $1317 to $296 per individual in the population. CONCLUSIONS With the increase in chemotherapy costs for advanced colorectal cancer, most colorectal cancer screening strategies have become cost saving. As a consequence, screening is a desirable approach not only to reduce colorectal cancer incidence and mortality but also to control the costs of colorectal cancer treatment.
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Affiliation(s)
- Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Trikalinos TA, Siebert U, Lau J. Decision-Analytic Modeling to Evaluate Benefits and Harms of Medical Tests: Uses and Limitations. Med Decis Making 2009; 29:E22-9. [DOI: 10.1177/0272989x09345022] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The clinical utility of medical tests is measured by whether the information they provide affects patient-relevant outcomes. To a large extent, effects of medical tests are indirect in nature. In principle, a test result affects patient outcomes mainly by influencing treatment choices. This indirectness in the link between testing and its downstream effects poses practical challenges to comparing alternate test-and-treat strategies in clinical trials. Keeping in mind the broader audience of researchers who perform comparative effectiveness reviews and technology assessments, the authors summarize the rationale for and pitfalls of decision modeling in the comparative evaluation of medical tests by virtue of specific examples. Modeling facilitates the interpretation of test performance measures by connecting the link between testing and patient outcomes, accounting for uncertainties and explicating assumptions, and allowing the systematic study of tradeoffs and uncertainty. The authors discuss challenges encountered when modeling test-and-treat strategies, including but not limited to scarcity of data on important parameters, transferring estimates of test performance across studies, choosing modeling outcomes, and obtaining summary estimates for test performance data.
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Affiliation(s)
- Thomas A. Trikalinos
- Tufts Evidence-based Practice Center and Center for Clinical Evidence Synthesis, Tufts Medical Center, Boston, Massachusetts,
| | - Uwe Siebert
- Department of Public Health, Medical Decision Making and Health Technology Assessment UMIT-University for Health Sciences, Medical Informatics and Technology, Hall I. T., Austria, Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical, School and Center for Health Decision Science, Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
| | - Joseph Lau
- Tufts Evidence-based Practice Center and Center for Clinical Evidence Synthesis, Tufts Medical Center, Boston, Massachusetts
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Developing and testing a cost-assessment tool for cancer screening programs. Am J Prev Med 2009; 37:242-7. [PMID: 19666160 DOI: 10.1016/j.amepre.2009.06.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2008] [Revised: 05/29/2009] [Accepted: 06/11/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cancer screening programs require substantial resources, and economic assessments have become increasingly important in identifying the most cost-effective means of conducting these programs. Such economic assessments require detailed program cost data, but there is no standardized instrument for obtaining these data. PURPOSE This study was designed to develop a standardized instrument to collect cost data from cancer screening programs. METHODS A cost-assessment tool (CAT) was developed to collect annual cost data based on the findings from case studies at four sites funded by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The data elements collected in the CAT were specifically tailored to collect cost and resource-use information from cancer screening programs. The tool was pilot-tested at nine NBCCEDP sites, and activity-based costs were generated by assigning all cost and resource-use data to specific program activities. Data were collected from November 2004 to February 2005, and the analysis was performed from March to July 2005. RESULTS Overall, a majority of the sites (eight of nine) met the acceptable threshold of <5% of total cost remaining unallocated. On average, the largest cost components of the nine programs were screening and diagnostic services (44.4%); recruitment (11.4%); database management (10.9%); and patient support/case management (9.3%). CONCLUSIONS Findings from the CAT pilot-testing showed that NBCCEDP cancer screening programs were able to report detailed activity-based cost data. The comparability of these cost data across programs should facilitate pooled analyses that, in turn, may lead to a better understanding of the impact and cost effectiveness of the screening program.
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Lansdorp-Vogelaar I, van Ballegooijen M, Boer R, Zauber A, Habbema JDF. A novel hypothesis on the sensitivity of the fecal occult blood test: Results of a joint analysis of 3 randomized controlled trials. Cancer 2009; 115:2410-9. [PMID: 19288570 DOI: 10.1002/cncr.24256] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Estimates of the fecal occult blood test (FOBT) (Hemoccult II) sensitivity differed widely between screening trials and led to divergent conclusions on the effects of FOBT screening. We used microsimulation modeling to estimate a preclinical colorectal cancer (CRC) duration and sensitivity for unrehydrated FOBT from the data of 3 randomized controlled trials of Minnesota, Nottingham, and Funen. In addition to 2 usual hypotheses on the sensitivity of FOBT, we tested a novel hypothesis where sensitivity is linked to the stage of clinical diagnosis in the situation without screening. METHODS We used the MISCAN-Colon microsimulation model to estimate sensitivity and duration, accounting for differences between the trials in demography, background incidence, and trial design. We tested 3 hypotheses for FOBT sensitivity: sensitivity is the same for all preclinical CRC stages, sensitivity increases with each stage, and sensitivity is higher for the stage in which the cancer would have been diagnosed in the absence of screening than for earlier stages. Goodness-of-fit was evaluated by comparing expected and observed rates of screen-detected and interval CRC. RESULTS The hypothesis with a higher sensitivity in the stage of clinical diagnosis gave the best fit. Under this hypothesis, sensitivity of FOBT was 51% in the stage of clinical diagnosis and 19% in earlier stages. The average duration of preclinical CRC was estimated at 6.7 years. CONCLUSIONS Our analysis corroborated a long duration of preclinical CRC, with FOBT most sensitive in the stage of clinical diagnosis.
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Affiliation(s)
- Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
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